Smoking and the Foot

It’s one thing podiatrists seem to know and seem to know well, if your patient is a smoker they have either begun to feel the pinch of the effect, the addictive habit has on their feet and legs or they soon will. Like anyone with an addiction whether legal or illegal the individual will not be able to make the decision to quit until they are ready to quit. Many would say that they would like too, many would say that they have tried but those have been successful have tried too; once, twice, five times or ten but eventually they got there and not one of those who have ceased the lifestyle regrets their decision. Yes, they may miss the smell, the socialization or the escape but regret is not a word you will hear uttered from their mouth.
Today we look how smoking affects the circulatory system and therefore the foot in our patient and in many cases also those friends and family member whom we care about.

Circulatory SystemThe Venous and Arterial System are two parts of an interdependent circulatory system which supplies oxygenated blood to the body while at the same time helping to remove metabolic bi-products. Veins are responsible for the transport of deoxygenated blood back to the lungs where they can release carbon dioxide and become re-oxygenated once again. The movement of the blood flow through venous return is considerably slower than that of its counter- part, the arteries, which are supported by powerful pumps of heart. The arteries are the transport system for the delivery of oxygenated blood to the tissues of the body via the centrally situated aorta and left ventricle pump to the most outer reaches that the body has to offer (I).

Explaining PAD/PVDPeripheral Vascular Disease is a development of atherosclerotic blood vessels in the smaller veins and arteries of the body, more commonly in the lower limb. Atherosclerosis within the blood vessels is the damaging of vessel walls and the build-up of fatty deposits. This can result in blockages which can reduce blood supply and potentially cause the development of clots within the vessels. The outcome of which can lead to a reduction in oxygen delivery to the body tissues, blood pooling and a build-up of metabolic products within the lower limb – manifesting into tissue death and significant pain.

Risk FactorsA number of risk factors have been identified throughout the literature regarding their influences of Peripheral Arterial Disease. By far the most significant is seen to be smoking causing 68% PAD in Males and 61% in females. Additionally, many lifestyle related health issues are seen to major contributors to this serious condition including; High Blood Pressure, Atherosclerosis, Diabetes, High Cholesterol, 60+ years of age and a Personal History of Vascular Disease.

Smoking and the Foot

100 year association between smoking and peripheral vascular disease

Number one modifiable lifestyle risk for PVD

Doubles chances of PVD

The more cigarettes smoked the greater the risk of PVD

There has been a significant push over the last decade or more to reduce the impact of second hand smoke on non-smokers and more specifically children. A major reason for this is the finding that second hand smoke has shown to increase the risk of coronary heart disease in non-smokers and the risk of heart attack by 30% (H).

SymptomsIt has been found that many people with PAD and PVD do not display any symptoms at all. However, the most common symptom which does appear is an intermittent pain in the legs which many people associate with aging rather than a serious medical condition. The intense pain and leg cramping will generally come about with exercise and cease soon after rest has begun. – this is known as intermittent claudication and is one of the early signs of PAD.

As the disease progresses the pain can also appear at rest and in the evening, this is known as critical leg ischemia and should be significant worry to the patient. It is common at this stage of the disease that leg ulcers may develop due to significant restriction in blood supply.

Furthermore, other symptoms which may show with PAD are colour changes in skin colour, the temperature in one leg being lower than the other, as well as poor hair and nail growth.

TreatmentThe primary goal of treatment of PAD is to reduce symptoms and progression of the disease by addressing the underlying causes of the condition. The prong in the attack is to make changes to the lifestyle of patients. The number one most important lifestyle change that can be made is the cessation of smoking.
Additionally, using a healthy eating plan, increasing exercise and reducing weight by having a health weight target is also extremely beneficial. These action alone do have the power to reduce the important and commonly high numbers associated with High Cholesterol, High Blood Pressure and Blood Glucose Levels.
However, sometime simple or in many cases large lifestyle changes are not enough to address the underlying health conditions. Smoking is an addictive habit which poses its very own problems, in addition to increasing exercise when a patient may already be in pain due to intermittent claudication. In this case medications are a great secondary prong of attack. Reducing leg pain will help patients begin to exercises (at least breaking down one of the barriers). Furthermore, blood clot prevention and specific medications used to lower the numbers of the conditions discussed above are of vital importance.

In some circumstances the best option is simply to undergo surgery. The invasive treatment can be used to restructure and bypass blood vessels to help increase blood supply to the peripheries of the limbs and reduce symptoms and progression to ischaemic limbs. Unfortunately, this too can be an overlooked option for too long and a decision may be made that surgical debridement (in case of wounds) or amputation may be the best option in saving the life of a patient.

ConclusionIt can be seen that the habit of smoking causes more than just lung cancer. In fact, it has been shown to have more effect on the vascular system than any other, significantly increasing the chances of Peripheral Arterial Disease, Peripheral Vascular Disease, Coronary Heart Disease and Stroke.
It is becoming more and more apparent that each of our lifestyle choices we participate in can have a large impact upon our health whether positively or negatively and that lifestyle based diseases are far outweighing those associated with pathogens. Next time you talk to your patient don’t let them “yeah yeah” your education of them away, challenge them and find out what’s holding them back.

Jackson McCoskerDirector /Chief Editor

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FootNotes Blogging was established by new graduate podiatrist Jackson McCosker in 2014 as a means of motivation to stay up to date with current evidence, clinical practice management, increasing client base and building professional credibility among peers and community organizations at all levels. FootNotes Blogging aims to provide accurate, up to date and well thought out management information in both a professional and entertaining format.
Although evidence based management is promoted within the forum, it should also be noted that much of that published by FootNotes Blogging is subjective in nature and general in suggested management practices. It is recommended that those reading seek one on one medical advice from a medical practitioner or podiatrist before following any advice [as per disclaimer].
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